Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 015593 | LA |
NPI | 1023019064 |
---|---|
Provider Name | Robert A. Nickelson |
First Address | Shreveport, LA 71103 |
Second Address | Shreveport, LA 71103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2005 |
Last Update Date | 18/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1322741 | (05) | LA |